Importance of Family Physicians in the diagnosis of Rheumatoid Arthritis

1. Rheumatoid Arthritis in Family
Medicine
The new diagnostic guidelines and the role of Family Physicians
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A I Haruna
April 23rd, 2020
Family Medicine

2. Purpose of this presentation
• To understand rationale for early recognition and treatment of RA
• To discuss the extent of involvement of the FP (open discussion)

3. Background
• RA as a chronic debilitating autoimmune disease
• Spontaneous remission without treatment is rare in RA
• Inexorably leads to functional decline and premature mortality
• 10-12% of rheumatology patients in SW Nigeria (Adelowo et al, 2017),
• 1% of general population globally, few studies in Africa (Dowman et al,
2012), regional variation, 30-60 yrs
• Rising because of urbanization and lifestyle
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4. Goal of treatment
• Ultimate outcome (hope for the future)
• Early suppression of inflammation and
achievement of early remission
• prevent joint damage and disability
• Quite achievable with early treatment

5. • Joint damage and loss of function occur early in the disease process
• Radiographic evidence of erosions among 70% (within 3 years), and 25% (within 3 months)
Van der Heijde et al, 1995
• MSUS and MRI shown evidence of damage within weeks
• Delay in treatment commencement associated with poorer outcomes (Van der Linden et al,
2010 and Van Nies et al 2014)
• Two group comparison ‘<12 week and >12 week after symptom onset’ comparison
• 1.3 times higher rate of joint destruction and HR of 1.87 for not achieving DMARD-free
remission in the >12 week group
• All pointers to early referral to Rheumatologist
• Only 31% of referred patients get rheumatology assessment within the 12 week mark
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6. How early is early?
• Window of opportunity: a limited period when the disease course can be altered or even reversed
• Cut off progressively decreased over the years: 5yrs, 2yrs, now 3mo v 12mo
• Very early RA: disease duration less than 3 months
• Late early RA: disease duration 3 months to 12 months
• Strongest predictor for dx remission at 6 months was a symptom duration of less than 12 weeks at the
time of treatment (Conaghen et al,1999)
• Clinical and radiographic outcomes were significantly better if treated before the 12 week mark (Nell et
al, 2004)
• ACR50 and DAS28 scores
• Response is nonlinear in terms of susceptibility to DMARDS (Emery et al, 2012)
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7. We should diagnose early
• 1987 ACR criteria: developed with a population of patients with late disease, low
sensitivity recent RA
• Means patients with early RA may not fulfill these criteria
• Rationale for review of criteria: Poor sensitivity for early dx, shift of focus from
‘established to early dx’, outcome oriented medicine, biologics and new tests
• 2010 ACR: emphasis on identifying patients with
• short symptom duration, and poor prognosis, that will benefit from early initiation
of DMARD therapy
• to be applied to all patients with undifferentiated inflammatory synovitis
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8. 2010 ACR/EULAR CLASSIFICATION CRITERIA
FOR RA
Joint involvement
1 large joint 0
2-10 large joint 1
1-3 small joints (+- large joints) 2
4-10 small joints (+- large joints) 3
>10 joints (at least one small joint) 5
Serology
Negative RF and Negative ACPA 0
Low positive RF or low positive ACPA 2
High positive RF or high positive ACPA 3
Acute phase reactant
Normal CRP AND Normal ESR 0
Abnormal CRP or Abnormal ESR 1
Duration of symptoms
Sx <6 weeks 0
Sx > or = 6 weeks 1
A SCORE OF 6 OR MORE NEEDED FOR CLASSIFICATION AS DEFINITE RA
ANY SCORE BELOW 6 IS UA
MCP,MTP,DIP excluded
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9. Exclude of inflammatory arthritis
• Undifferentiated arthritis: 30% remit, 30% develop RA, 20% remain UA
• 3 or more swollen joints, MTP/MCP involvement, EMS >30 minutes
• Extra-articular manifestations: late in RA, early in SLE, ReA, PsA,
Sarcoidosis help rule out differentials
• CBC, ESR, RF, CRP, ACPA to confirm RA,
• X-rays, MRI, MSUS

10. Prognostic Factors
Predictors of disease persistence / erosive
arthritis
Predictors of disease severity
Female gender
High joint count
Positive RF, ACPA
Raised acute phase reactants (ESR, CRP)
Duration of symptoms High HAQ score
Hand involvement Shared epitope
Erosions on X-ray Erosive disease
HAQ: Health Assessment Questionnaire
ACPA: Anticyclic Citrillunated Peptide Antibody

11. • FM based predictors: Family and social support, environmental factors
• High HAQ score: either at diagnosis or at 1 year (Wiles et al, 2000)
• ESR and CRP: Utility more than additive
• RF quantitative
• Shared epitope (SE) and family history
• Early morning stiffness no more relevant (Funovits et al, 2010)
• Smoking is the strongest environmental risk factor, formation of ACPA (esp with SE)

12. Phases up to the development of RA
Genetic factors
Environmental factors
Systemic autoimmunity
symptoms without clinical arthritis
Unclassified arthritis
RA
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Symptoms
Time
Response to DMARDS
12 wk
12 wk
Nonlinear response to DMARDS

13. In Summary
• 2010 ACR/EULAR classification criteria will push the numbers up
• more objectivity, shifts attention to early disease, congest rheumatology
clinic
• Early identification and institution of treatment is the standard (presented
later)
• Prognostic factors equally as necessary
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14. Discussion
• What roles do FP play? Identify and diagnose early RA
• At what point do we refer? As soon as we ID inflammatory arthritis
• Other thoughts…..
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15. Thank you
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